Obtaining Vitamin D Levels in Children With Fractures Improves Supplementation Compliance.

BACKGROUND: Obtaining ideal serum 25-vitamin D (25VitD) levels (>30 ng/mL) is imperative in childhood to achieve peak bone mass. Supplementation compliance in children recommended to take vitamin D postfracture was evaluated. The questions we sought to answer were: Is there (1) a compliance difference between patients with known versus unknown 25VitD levels; (2) an association between compliance and age; and (3) an association between fracture severity and initial 25VitD level. METHODS: One physician analyzed compliance in 1818 fracture patients 2 to 18 years (42% female) with known (48%) and unknown 25VitD. Patient/caregiver's self-reported adherence to supplementation as "yes" (4 d/wk minimum) or "no" defined compliance. Compliance relating to fracture severity via Abbreviated Injury Scale (AIS), 25VitD level, and age, was analyzed. RESULTS: Patients with 25VitD levels were more compliant than patients without (61%, n=532/872; 21%, n=206/946; P<0.001). In total, 83% (n=104/125) of AIS 3 patients were compliant, compared with 49% (n=628/1292) of AIS 1/2 patients (P<0.001). Compliance increased with age (odds ratio: 1.09, 95% confidence interval: 1.061-1.120, P<0.001). CONCLUSIONS: Compliance increased when 25VitD levels were obtained, improving with fracture severity. Clinicians should order 25VitD levels on fracture patients to improve supplementation compliance. LEVEL OF EVIDENCE: This is a level IV prognostic study which aims to investigate the effects of various patient characteristics on compliance.

Complementary Serologic Investigations in Children with Celiac Disease Is Unnecessary during Follow-Up.

OBJECTIVES: To determine the frequency of nutritional deficiencies and thyroid dysfunction in children with celiac disease (CD) and during follow-up after initiation of a gluten-free diet. Laboratory investigations of hemoglobin, ferritin, calcium, folate, vitamin B12, vitamin D, and thyroid function are regularly ordered in children with CD despite sufficient evidence for these. STUDY DESIGN: Between 2009 and 2014, test results of hemoglobin, ferritin, folate, vitamin B12, calcium, vitamin D (25[OH]D), free thyroxin, and thyroid stimulating hormone of children with CD regularly seen at the Leiden University Medical Center were investigated. Laboratory reference ranges were used to define abnormal results. Pearson χ(2) test for trend, unpaired t test, and 1-way ANOVA were used for statistical analysis. RESULTS: Of the 182 children evaluated, 119 were newly diagnosed. On average, 17% of results per year were missing because of incomplete blood investigations. Iron deficiency (28%) and iron deficiency anemia (9%) were found at the time of diagnosis of CD. Folate (14%), vitamin B12 (1%), and vitamin D deficiencies (27%) were also seen. No hypocalcemia or thyroid dysfunction was found. At follow-up, iron deficiency, iron deficiency anemia, and folate and vitamin D deficiency were observed in 8%, 2%, 3%, and 25% of patients, respectively. Vitamin B12 deficiency, hypocalcemia, and thyroid disease were not found. CONCLUSIONS: Complementary blood investigations are relevant at the time of diagnosis of CD but have little diagnostic yield during follow-up visits once the patient is placed on a gluten-free diet. Thus, we recommend that these variables only be assessed on indication, such as fatigue or abnormal growth.

Larger differences in utilization of rarely requested tests in primary care in Spain.

INTRODUCTION: The study was performed to compare and analyze the inter-departmental variability in the request of rarely requested laboratory tests in primary care, as opposed to other more common and highly requested tests. MATERIALS AND METHODS: Data from production statistics for the year 2012 from 76 Spanish laboratories was used. The number of antinuclear antibodies, antistreptolysin O, creatinine, cyclic citrullinated peptide antibodies, deaminated peptide gliadine IgA antibodies, glucose, protein electrophoresis, rheumatoid factor, transglutaminase IgA antibodies, urinalysis and uric acid tests requested was collected. The number of test requests per 1000 inhabitants was calculated. In order to explore the variability the coefficient of quartile dispersion was calculated. RESULTS: The smallest variation was seen for creatinine, glucose, uric acid and urinalysis; the most requested tests. The tests that were least requested showed the greatest variability. CONCLUSION: Our study shows through a very simplified approach, in a population close to twenty million inhabitants, how in primary care, the variability in the request of laboratory tests is inversely proportional to the request rate.

Oral care may reduce pneumonia in the tube-fed elderly: a preliminary study.

Pneumonia is one of the most important diseases in terms of mortality in the elderly. In particular, bedridden patients who are forbidden oral ingestion during enteral nutrition may have a poor outcome resulting from a respiratory infection. Oral hygiene can play a positive role in preventing aspiration pneumonia in the elderly. The aim of this study was to investigate the effectiveness of oral hygiene for bedridden and tube-fed patients at an increased risk of pneumonia. This retrospective study was conducted from July 2011 to June 2013 on a long-term-care hospital unit. The oral care protocol (OCP) intervention commenced in July 2012, during the study period. The subjects of this study were 63 elderly patients with a mean age of 81.7 years. Thirty-one patients were enrolled in the OCP intervention group, and the mean observation length was 130.4 days; the mean observation length for the 32 patients in the control group was 128.4 days. The incidence of pneumonia and the numbers of days with a recorded fever, antibiotics administration, blood tests, and radiological examinations were reduced from 1.20 to 0.45, 24.57 to 17.48, 25.52 to 10.12, 10.91 to 6.54, and 6.33 to 3.09 %, respectively. These reductions were significantly less in the OCP intervention group. In conclusion, the results of the present study suggest that daily oral care for tube-fed patients who do not receive nutrition by mouth reduced the incidence of pneumonia. In addition to patients consuming food by mouth, all tube-fed patients require dedicated oral care to maintain healthy oral conditions.

Pediatric constipation in the emergency department: evaluation, treatment, and outcomes.

OBJECTIVES: Limited knowledge exists surrounding the pharmacologic management of pediatric constipation in the emergency department (ED) setting and the success of interventions. Our primary objective was to determine whether enema administration is associated with 7-day ED revisits for persistent symptoms. Secondary objectives focused on assessing other predictors of ED revisits. METHODS: We conducted a retrospective cohort study of children <18 years old, diagnosed as having constipation (International Classification of Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a pediatric ED in Toronto, Canada, between November 2008 and October 2010. RESULTS: A total of 3592 visits were included; 6% (n = 225) were associated with a revisit. Children with revisits more frequently had vomiting (28% vs 17%, P = 0.001), more pain (5.7 ±â€Š3.6 vs 4.6-3.6 of 10, P = 0.01), and underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of the difference 3%-14%] and diagnostic imaging (62% vs 47%, 95% CI of the difference 9%-22%). Children administered an enema were 1.54 times more likely to revisit the ED than those who did not receive an enema (8.6% vs 5.5%, 95% CI of the difference 1.1%-5.2%, P = 0.001). Type of enema administered varied by age (P < 0.001). Regression analysis identified the following independent predictors of revisits: diagnostic imaging (odds ratio [OR] 1.54, 95% CI 1.15-2.06), vomiting (OR 1.45, 95% CI 1.07-1.98), enema administration (OR 1.40, 95% CI 1.05-1.88), and significant medical history (OR 1.26, 95% CI 1.04-1.53). CONCLUSIONS: Enema administration and diagnostic imaging are associated with revisits in children diagnosed with constipation. Their role in the ED management of pediatric constipation requires further evaluation.

Yield of recommended blood tests for neonates requiring phototherapy for hyperbilirubinemia.

BACKGROUND: Hyperbilirubinemia of the newborn is common. Rarely is an underlying disease other than physiologic hyperbilirubinemia considered the cause of high bilirubin levels. Some of the laboratory tests recommended by the American Academy of Pediatrics are expensive and do not always lead to diagnosis. OBJECTIVE: To evaluate the efficacy of standard laboratory tests performed on newborn infants requiring phototherapy for hyperbilirubinaemia. METHODS: We conducted a retrospective chart review that included neonates born during a 6 month period with birth weight 2500 g treated with phototherapy for hyperbilirubinemia (n = 282) according to published guidelines. The main outcome measures were primary and maximal bilirubin values (mg/dl), time to jaundice (in days), the number of bilirubin tests undertaken and whether the patient showed abnormal functioning, and the number of days in follow-up. RESULTS: Thirty-three neonates (11.7%) were positive in at least one laboratory test (defined as "Abnormal" in our study), 45.5% of whom met the criteria for phototherapy during the first 48 hours of life. Among the newborns who were negative for all laboratory tests (defined as "Normal"), only 6.8% met phototherapy criteria within their first 48 hours of life (P < 0.001). In the Normal group there was a consistent decrease in total serum bilirubin values shortly after phototherapy was begun, while the Abnormal group presented an increase in serum bilirubin values during the first 12 hours of phototherapy. None of the infants had conjugated (direct) hyperbilirubinemia during the study period. CONCLUSIONS: Most neonates presenting with a laboratory identifiable etiology for hyperbilirubinemia (i.e., hemolysis) can be distinguished from those who test negative, mainly based on the timing of presentation and response to phototherapy. A more meticulous selection of patients and reduction in the magnitude of routine laboratory testing can safely reduce discomfort to infants with hyperbilirubinemia as well as costs.

Comparative safety and efficacy of two high dose regimens of oral paracetamol in healthy adults undergoing third molar surgery under local anaesthesia.

This study compared the efficacy and safety of single oral doses of 60 mg/kg and 90 mg/kg paracetamol in fit young adult patients undergoing third molar extractions. The study was a randomised, blinded, crossover design on 20 young, fit adults. Paracetamol was administered 30 minutes prior to the surgical extraction of the teeth, which was done under intravenous sedation and local anaesthesia. There were no clinically or statistically significant differences in the pain scores between 60 mg/kg or 90 mg/kg doses until the intake of rescue analgesics. There was a reduction in factor VII activity with 90 mg/kg dose compared to 60 mg/kg dose. It may be concluded that the 90 mg/kg dose, though safe, does not offer any advantages over 60 mg/kg dose of paracetamol in young fit adults undergoing third molar surgery.

[The morphological characteristics of the circulating blood after massive reinfusion in operative surgery]. / Morfologichna kharakteristika na tsirkulirashtata kruv sled masivna reinfuziia v operativnata khirurgiia.

Intraoperative autologous blood extravasation represents an adequate biogenic medium for prompt and complete blood volume compensation following acute hemorrhage. The efficiency of the procedure is closely related to the functional characteristics of the ATS applied and its potential adaptation to the operative field. Over a 5-year period, autologous blood reinfusion is done in 151 patients with acute intraoperative hemorrhage associated with various types of operative interventions. The hemogram is analyzed in 32 cases undergoing reconstructive surgery of arterial vessels, with massive intraoperative hemorrhage and reinfusion (exceeding 25 per cent of the circulating volume). The quantity of AB represents 92.7 per cent of the blood loss volume; reinfusion is effected using the patient's own ATS. The circulating erythron level (its binding portion) remains within reference limits throughout the full post-reinfusion period; a tendency towards complete correlative dependence between the values of Hb, Er, Ht and the volume of reinfusion done intraoperatively is outlined (r = 0.84-0.92; p < 0.05-0.001). Free hemoglobin concentration in the transfusion product is low (66.8 +/- 24.2 mg/100 ml blood), while in the post-reinfusion circulating blood it quickly returns to normal, at 2 hours--in 87.5 per cent of the samples, and at 6 hours--in 100 per cent (r = 0.66-0.80; p > 0.001). The minimal morphologic changes in AB upon its deposition and reinfusion warrant the assumption that it is the most suitable transfusion medium, contributing to normalization of the hematologic indicators of acute hemorrhage during operative surgery.